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I am over the age of 18 and desire Mileide Marques (Milly), Monique Marques (Niki), Heather Petty-Harris, Kethulla Castro (Kate) and Thay Mesquita to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).


Date: April 24, 2024

I also understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the permanent cosmetic make-up application. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong. I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).


Date: April 24, 2024

For the purpose of documentation, I also consent to the taking of before, during and after photographs / videos of said procedure(s) which become the technician's sole property and may or may not be used for what ever purpose deemed necessary including using pictures for social media and advertising publications. IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN SHE WILL MARK YOUR SKIN WITH AN (X) PRIOR TO TAKING PHOTOS. Understanding the permanent skin pigmentation procedure, the procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Mileide Marques (Milly), Monique Marques (Niki), Heather Petty-Harris, Kethulla Castro (Kate) OR Thay Mesquita to perform the permanent skin pigmentation procedure(s). Please sign Yes or No.

Date: April 24, 2024

I understand Microblading and any elective permanent make up is considered a tattoo in the State of Georgia and I will not be able to donate blood for one year. Please check state laws before donating blood. 


Date: April 24, 2024

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.



First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*

Phone*
Second Client's Date of Birth*
Second Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Third Client's Name

First Name*

Last Name*

Phone*
Third Client's Date of Birth*
Third Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Fourth Client's Name

First Name*

Last Name*

Phone*
Fourth Client's Date of Birth*
Fourth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Fifth Client's Name

First Name*

Last Name*

Phone*
Fifth Client's Date of Birth*
Fifth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Sixth Client's Name

First Name*

Last Name*

Phone*
Sixth Client's Date of Birth*
Sixth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Seventh Client's Name

First Name*

Last Name*

Phone*
Seventh Client's Date of Birth*
Seventh Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Eighth Client's Name

First Name*

Last Name*

Phone*
Eighth Client's Date of Birth*
Eighth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Ninth Client's Name

First Name*

Last Name*

Phone*
Ninth Client's Date of Birth*
Ninth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Tenth Client's Name

First Name*

Last Name*

Phone*
Tenth Client's Date of Birth*
Tenth Client's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Referred by:
Check if you answer YES to any of these questions: *
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you currently under the influence of alcohol or recreational drugs?
Have you had botox or any facial injection in the last 3 weeks? (forehead or between eyebrows ONLY) If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you consent to getting your eyebrows waxed?
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
None of the above

Are you presently taking any medications? List:

Are you allergic to any foods or medications?

Are you presently under a physician's care? What for?

Please inital: 


Do you agree to the fees discussed?

I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300. charge depending upon the amount of work needed. There is a possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic. Laser treatments or ANY kid of facial injections may also compromise your permanent cosmetic makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results. 

Please select all that apply : I request permanent cosmetic make-up procedures:
Microblading

Other:

Medical Consent and Procedure Chart 

Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*
No
Yes
New Option
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*
No
Yes
New Option
Do you have any allergies to any medication or latex?*
No
Yes
Novocain, Lidocain or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe.

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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